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20 C.F.R. §§ 418.3101–418.3125

7 sections in range

§418.3101. How do you become eligible for a subsidy?

20 C.F.R. § 418.3101

Unless you are deemed eligible as explained in § 418.3105 and 42 CFR 423.773(c), you are eligible for a Medicare Part D prescription drug subsidy if you meet all of the following requirements:
(a)
You are entitled to or enrolled in Medicare Part A (Hospital Insurance) or enrolled in Medicare Part B (Supplementary Medical Insurance) or both under title XVIII of the Act.
(b)
You are enrolled in a Medicare prescription drug plan or Medicare Advantage plan with prescription drug coverage. We can also determine your eligibility for a subsidy before you enroll in one of the above programs. However, as explained in § 418.3225(b), if we determine that you would be eligible for a subsidy before you have enrolled in a Medicare prescription drug plan or Medicare Advantage plan with prescription drug coverage, you must enroll in one of these plans to actually receive a subsidy.
(c)
You reside in the United States as defined in § 418.3010.
(d)
You (and your spouse, if applicable) meet the income requirements as explained in §§ 418.3301 through 418.3350 and 42 CFR 423.773.
(e)
You (and your spouse, if applicable) meet the resources requirements as explained in §§ 418.3401 through 418.3425 and 42 CFR 423.773.
(f)
You or your personal representative file an application for a subsidy as explained in §§ 418.3201 through 418.3230.
Notes, amendments, and revision history

Authority

Authority: Secs. 702(a)(5) and 1860D-1, 1860D-14 and -15 of the Social Security Act (42 U.S.C. 902(a)(5),1395w-101, 1395w-114, and -115).

Source

Source: 70 FR 77675, Dec. 30, 2005, unless otherwise noted.

§418.3105. Who does not need to file an application for a subsidy?

20 C.F.R. § 418.3105

Regulations in 42 CFR 423.773(c) explain who is deemed eligible and does not need to file an application for a subsidy to be eligible for this assistance. Full-benefit dual eligible beneficiaries are in this category. If beneficiaries have deemed eligibility status because they receive Medicaid coverage, are enrolled in a Medicare Savings Program within their State, or receive SSI and have Medicare, then their subsidy is effective with the first month they have deemed eligibility status.
Notes, amendments, and revision history

Authority

Authority: Secs. 702(a)(5) and 1860D-1, 1860D-14 and -15 of the Social Security Act (42 U.S.C. 902(a)(5),1395w-101, 1395w-114, and -115).

Source

Source: 70 FR 77675, Dec. 30, 2005, unless otherwise noted.

§418.3110. What happens when you apply for a subsidy?

20 C.F.R. § 418.3110

(a)
When you or your personal representative apply for a subsidy, we will ask for information that we need to determine if you meet all the requirements for a subsidy. You must give us complete information. If, based on the information you present to us, you do not meet all the requirements for eligibility listed in § 418.3101, or if one of the events listed in § 418.3115 exists, or you fail to submit information we request, we will deny your claim.
(b)
If you meet all the requirements for eligibility listed in § 418.3101, or you meet all the requirements except for enrollment in a Medicare Part D plan or Medicare Advantage plan with prescription drug coverage, we will send you a notice telling you the following:
(1)
You are eligible for a full or partial subsidy for a period not to exceed 1 year;
(2)
What information we used to make this determination including how we calculated your income and resources;
(3)
What you may do if your circumstances change as described in § 418.3120; and
(4)
Your appeal rights.
(c)
If you are not already enrolled with a Medicare prescription drug plan or a Medicare Advantage plan with prescription drug coverage, you must enroll in order to receive your subsidy.
(d)
If you do not meet all the requirements for eligibility listed in § 418.3101 or if § 418.3115 applies to you except for enrollment in a Medicare Part D plan or Medicare Advantage plan with prescription drug coverage as described in § 418.3225, we will send you a notice telling you the following:
(1)
You are not eligible for a subsidy;
(2)
The information we used to make this determination including how we calculated your income or resources;
(3)
You may reapply if your situation changes; and
(4)
Your appeal rights.
Notes, amendments, and revision history

Authority

Authority: Secs. 702(a)(5) and 1860D-1, 1860D-14 and -15 of the Social Security Act (42 U.S.C. 902(a)(5),1395w-101, 1395w-114, and -115).

Source

Source: 70 FR 77675, Dec. 30, 2005, unless otherwise noted.

§418.3115. What events will make you ineligible for a subsidy?

20 C.F.R. § 418.3115

Generally, even if you meet the other requirements in §§ 418.3101 through 418.3125, we will deny your claim or you will lose your subsidy if any of the following apply to you:
(a)
You lose entitlement to or are not enrolled in Medicare Part A and are not enrolled in Medicare Part B.
(b)
You do not enroll or lose your enrollment in a Medicare Part D plan or Medicare Advantage plan with prescription drug coverage.
(c)
You do not give us information we need to determine your eligibility and if eligible, whether you should receive a full or partial subsidy; or you do not give us information we need to determine whether you continue to be eligible for a subsidy and if eligible, whether you should receive a full or partial subsidy.
(d)
You knowingly give us false or misleading information.
Notes, amendments, and revision history

Authority

Authority: Secs. 702(a)(5) and 1860D-1, 1860D-14 and -15 of the Social Security Act (42 U.S.C. 902(a)(5),1395w-101, 1395w-114, and -115).

Source

Source: 70 FR 77675, Dec. 30, 2005, unless otherwise noted.

§418.3120. What happens if your circumstances change after we determine you are eligible for a subsidy?

20 C.F.R. § 418.3120

(a)
After we determine that you are eligible for a subsidy, your subsidy eligibility could change if—
(1)
You marry.
(2)
You and your spouse, who lives with you, divorce.
(3)
Subject to the provisions of paragraph (b)(4) of this section, your spouse, who lives with you, dies.
(4)
You and your spouse separate (i.e., you or your spouse move out of the household and you are no longer living with your spouse) unless the separation is a temporary absence as described in § 404.347 of this chapter.
(5)
You and your spouse resume living together after having been separated.
(6)
You and your spouse, who lives with you, have your marriage annulled.
(7)
You (or your spouse, who lives with you, if applicable) expect your estimated annual income to increase or decrease in the next calendar year.
(8)
You (or your spouse, who lives with you, if applicable) expect your resources to increase or decrease in the next calendar year.
(9)
Your family size as defined in 42 CFR 423.772 has changed or will change (other than a change resulting from one of the events in paragraphs (a)(1) through (6) of this section).
(10)
You become eligible for one of the programs listed in 42 CFR 423.773(c).
(b)
(1)
When you report one of the events listed in paragraphs (a)(1) through (a)(6) of this section, or we receive such a report from another source (e.g., a data exchange of reports of death), we will send you a redetermination form upon receipt of the report. You must return the completed form within 90 days of the date of the form.
(2)
When you report one of the events listed in paragraphs (a)(7) through (a)(9) of this section or we receive such a report from another source (e.g., a data exchange involving income records), we will send you a redetermination form between August and December to evaluate the change. You must return the completed form to us within 30 days of the date of the form.
(3)
If we increase, decrease, or terminate your subsidy as a result of the redetermination, we will send you a notice telling you:
(i)
Whether you can receive a full or partial subsidy as described in 42 CFR 423.780 and 423.782.
(ii)
How we calculated your income and resources;
(iii)
When the change in your subsidy is effective;
(iv)
Your appeal rights;
(v)
What to do if your situation changes.
(4)
If your spouse who lives with you dies, your spouse's death may result in changes in your income or resources that could decrease or eliminate your subsidy. If we are informed of the death of your spouse and the death would cause a decrease in or elimination of your subsidy, we will notify you that we will not immediately change your subsidy because of your spouse's death. We will defer your redetermination for 1 year from the month following the month we are notified of the death of your spouse, unless we receive a report of another event specified in 418.3120(a) that would affect your eligibility for a subsidy.
(c)
If you become eligible for one of the programs listed in 42 CFR 423.773(c), CMS will notify you of any change in your subsidy.
Notes, amendments, and revision history

Amendments

[70 FR 77675, Dec. 30, 2005, as amended at 75 FR 81845, Dec. 29, 2010]

Authority

Authority: Secs. 702(a)(5) and 1860D-1, 1860D-14 and -15 of the Social Security Act (42 U.S.C. 902(a)(5),1395w-101, 1395w-114, and -115).

Source

Source: 70 FR 77675, Dec. 30, 2005, unless otherwise noted.

Amendments

[70 FR 77675, Dec. 30, 2005, as amended at 75 FR 81845, Dec. 29, 2010]

§418.3123. When is a change in your subsidy effective?

20 C.F.R. § 418.3123

(a)
If we redetermine your subsidy as described in § 418.3120(b)(1), any change in your subsidy will be effective the month following the month of your report.
(b)
If we redetermine your subsidy as described in § 418.3120(b)(2), any change in your subsidy will be effective in January of the next year.
(c)
If you do not return the redetermination form described in § 418.3120(b)(1), we will terminate your subsidy effective with the month following the expiration of the 90-day period described in § 418.3120(b)(1).
(d)
If you do not return the redetermination forms described in § 418.3120(b)(2), we will terminate your subsidy effective in January of the next year.
(e)
Special rule for widows and widowers. If your spouse who lives with you dies and the changes in your income or resources resulting from your spouse's death would decrease or eliminate your subsidy, we will defer your next redetermination for 1 year from the month following the month we are notified of the death of your spouse, unless we receive a report of another event specified in 418.3120(a) that would affect your eligibility for a subsidy.
Notes, amendments, and revision history

Amendments

[70 FR 77675, Dec. 30, 2005, as amended at 75 FR 81845, Dec. 29, 2010]

Authority

Authority: Secs. 702(a)(5) and 1860D-1, 1860D-14 and -15 of the Social Security Act (42 U.S.C. 902(a)(5),1395w-101, 1395w-114, and -115).

Source

Source: 70 FR 77675, Dec. 30, 2005, unless otherwise noted.

Amendments

[70 FR 77675, Dec. 30, 2005, as amended at 75 FR 81845, Dec. 29, 2010]

§418.3125. What are redeterminations?

20 C.F.R. § 418.3125

(a)
Redeterminations defined. A redetermination is a periodic review of your eligibility to make sure that you are still eligible for a subsidy and if so, to determine whether you should continue to receive a full or partial subsidy. This review deals with evaluating your income and resources (and those of your spouse, who lives with you) and will not affect past months of eligibility. It will be used to determine your future subsidy eligibility and whether you should receive a full or partial subsidy for future months. We will redetermine your eligibility if we made the initial determination of your eligibility or if you are deemed eligible because you receive SSI benefits. Rules regarding redeterminations of initial eligibility determinations made by a State are described in 42 CFR 423.774.
(b)
When we make redeterminations.
(1)
We will redetermine your subsidy eligibility within one year after we determine that you are eligible for the subsidy.
(2)
After the first redetermination, we will redetermine your subsidy eligibility at intervals determined by the Commissioner. The length of time between redeterminations varies depending on the likelihood that your situation may change in a way that affects your eligibility and whether you should receive a full or partial subsidy.
(3)
We may also redetermine your eligibility and whether you should receive a full or partial subsidy when you tell us of a change in your circumstances described in § 418.3120.
(4)
We may redetermine your eligibility when we receive information from you or from data exchanges with Federal and State agencies that may affect whether you should receive a full or partial subsidy or your eligibility for the subsidy.
(5)
We will also redetermine eligibility on a random sample of cases for quality assurance purposes. For each collection of sample cases, all factors affecting eligibility and/or whether you should receive a full or partial subsidy may be verified by contact with primary repositories of information relevant to each individual factor (e.g., we may contact employers to verify wage information). Consequently, we may contact a variety of other sources, in addition to recontacting you, to verify the completeness and accuracy of our information.
Notes, amendments, and revision history

Authority

Authority: Secs. 702(a)(5) and 1860D-1, 1860D-14 and -15 of the Social Security Act (42 U.S.C. 902(a)(5),1395w-101, 1395w-114, and -115).

Source

Source: 70 FR 77675, Dec. 30, 2005, unless otherwise noted.